20201786 Ver 1_401 Application_20201120

Staff Review Form •
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En vironmenfrr!QvoGry
Updated September 4,2020
Staff Review
Does this application have all the attachments needed to accept it into the review process?*
6* Yes r No
ID#* Version* 1
20201786
Is this project a public transportation project?* (' Yes
r No
Is this a DOT ( Yes C No
project?*
Reviewer List:* Joanne Steenhuis:eads\jhsteenhuis
Select Reviewing Office:* Wilmington Regional Office-[phone]
Does this project require a request for payment to be sent?*
Yes
r
No

Project Submittal Form
Please note:fields marked with a red asterisk *below are required. You will not be able to submit the form until all
mandatory questions are answered.
Project Type:* r For the Record Only(Courtesy Copy)
r New Project
r Modification/New Project with Existing ID
✓ More Information Response
✓ Other Agency Comments
r Pre-Application Submittal
✓ Re-Issuance\Renewal Request
✓ Stream or Buffer Appeal
Project Contact Information
Name: NCDOT Division 6
Who is submitting the information?
Email Address: [e-mail]
Project Information
Project Name: Replace Bridge No.080175 on SR 1124 over Boots Swamp
Is this a public transportation project?
r Yes
✓ No
Is the project located within a NC DCM Area of Environmental Concern (AEC)?
✓ Yes r No r Unknown
TIP#: WBS#:
17BP.6.R.73
(Applies to DOT projects only)
County(ies)
Bladen
Please upload all files that need to be submited.
Click the upload button or drag and drop files here to attach document
17BP.6.R.73 Permit Drawings Final.pdf 1.47MB
Only pa or krrz files are accepted.
Describe the attachments
or comments:
Lat/Long Coordinates:34.607578,-78.788075
Bridge Project for Non-reporting NWP#3 and GC#4132.
Sign and Submit
.......................................................................................................................................................................................................................................................................................................................................................................................................
117 By checking the box and signing box below, I certify that:
■ I,the project proponent, hereby certifies that all information contained herein is true,accurate, and complete to

the best of my knowledge and belief.
■ I,the project proponent, hereby requests that the certifying authority review and take action on this CWA 401
certification request within the applicable reasonable period of time.
■ I agree that submission of this online form is a"transaction"subject to Chapter 66,Article 40 of the NC General
Statutes(the"Uniform Electronic Transactions Act");
■ I agree to conduct this transaction by electronic means pursuant to Chapter 66,Article 40 of the NC General
Statutes(the"Uniform Electronic Transactions Act");
■ I understand that an electronic signature has the same legal effect and can be enforced in the same way as a
written signature;AND
■ I intend to electronically sign and submit the online form.
Signature:
Submittal Date: Is filled in autor atically.